Client Intake Form

Required Information: Intake forms that are submitted without the required information will not be processed

Required: Documentation the patient has been diagnosed with Autistic Disorder (Diagnosis Code F84.0)

Required: If insurance is being used to pay for part or all ABA services, a copy of the front and back of your primary insurance card is required.

Required: If secondary insurance is being used to pay for part of ABA services, a copy of the front and back of your secondary insurance card is required.

Restrictions & Exclusions

We do not currently accept the following insurance plans: Sunshine Medicaid, CMS (Children’s Medical Services, United Behavioral Health/United Healthcare.

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CLIENT INFORMATION SECTION

Email Address *

Does your child have an autism diagnosis (F84.0) from a physician? *

DO NOT CONTINUE OR SUBMIT We thank you for your interest in Awetism Wonderland but a diagnosis code of F84.0 and a referral from a physician is required to enroll as a patient. Please contact us again once you have a physician's diagnosis.

Are you looking for PT/OT/ST services? *

do Self-Pay any

DO NOT CONTINUE OR SUBMIT In order for your intake form to be processed, you need to (1) have a diagnosis of F84.0 (Autism Disorder) and (2) Not be looking for PT/OT/ST services. Those looking for PT/OT/ST follow up via the following website. https://www.playworkstherapies.com/patient-portal

Services Requested *

ABA Therapy Only
ABA Therapy & Academics

NOTE: Academics are only available in conjunction with ABA Therapy.

Patient's Name *

First

Last

Patient's Date of Birth *

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Who referred you/where did you find us? *

PARENT/GUARDIAN INFORMATION SECTION

Parent/Guardian Name *

First

Last

Relationship To Patient *

Home Phone Number *

Cell Phone Number *

Work Phone Number *

Best phone number to contact you at

Second Parent/Guardian Name

First

Last

Relationship To Patient

Email Address

Cell Phone Number *

EMERGENCY CONTACT INFORMATION SECTION

Name Of Emergency Contact *

First

Last

Emergency Contact Phone Number *

Relationship To Patient

If other please explain

Preferred Hospital *

PRIMARY CARE PHYSICIAN INFORMATION SECTION

Primary Care Physician's Name *

First

Last

Primary Care Physician's Phone Number *

DIAGNOSIS & SERVICES SECTION

Service Location Being Requested *

Desired Schedule *

Desired number of days per week

Selected Value: 1

Please provide a summary of your needs/expectations for your child for ABA therapy. *

Please provide a summary of your needs/expectations for your child if also seeking academics. *

Is the child currently enrolled in school or an academic program? *

Name of the school or program where the student is currently enrolled *

Current Grade Level of Student *

PRIMARY INSURANCE INFORMATION SECTION

We do not currently accept the following insurance for ABA Therapy

Sunshine Medicaid – CMS (Children’s Medical Services – United Behavioral Health – United Healthcare

Medical Insurance or Self-Pay *

Name of primary insurance company *

Primary Insurance Member ID/Policy Number *

Policy Holder's Name *

First

Last

Policy Holder's Date of Birth *

Employer's Name *

SECONDARY INSURANCE INFORMATION SECTION

Do you have secondary insurance coverage *

Name of secondary insurance company *

Secondary Insurance Member ID/Policy Number *

Secondary Policy Holder's Name *

First

Last

Secondary Policy Holder's Date of Birth *

Employer's Name *

SCHOLARSHIP SECTION

Specify the name of any scholarship/ you may be using if applicable

Specify the approximate amount of the scholarship mentioned

Upload a copy of the autism diagnosis from a physician *

Drag & Drop Files, Choose Files to Upload You can upload up to 2 files.

Valid file extensions are .doc, .pdf, .png, .gif, .docx, .jpg, .jpeg. Max file size is 15MB.

Upload an image of the front and back of your primary insurance card *

Drag & Drop Files, Choose Files to Upload You can upload up to 2 files.

Valid file extensions are .doc, .pdf, .png, .gif, .docx, .jpg, .jpeg. Max file size is 15MB.

Upload an image of the front and back of your secondary insurance card *

Drag & Drop Files, Choose Files to Upload You can upload up to 2 files.

Valid file extensions are .doc, .pdf, .png, .gif, .docx, .jpg, .jpeg. Max file size is 15MB.

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Hello!

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Client Intake Form

Required Information: Intake forms that are submitted without the required information will not be processed

Restrictions & Exclusions

CLIENT INFORMATION SECTION

DO NOT CONTINUE OR SUBMIT We thank you for your interest in Awetism Wonderland but a diagnosis code of F84.0 and a referral from a physician is required to enroll as a patient. Please contact us again once you have a physician's diagnosis.

DO NOT CONTINUE OR SUBMIT In order for your intake form to be processed, you need to (1) have a diagnosis of F84.0 (Autism Disorder) and (2) Not be looking for PT/OT/ST services. Those looking for PT/OT/ST follow up via the following website. https://www.playworkstherapies.com/patient-portal

PARENT/GUARDIAN INFORMATION SECTION

EMERGENCY CONTACT INFORMATION SECTION

PRIMARY CARE PHYSICIAN INFORMATION SECTION

DIAGNOSIS & SERVICES SECTION

PRIMARY INSURANCE INFORMATION SECTION

We do not currently accept the following insurance for ABA Therapy

SECONDARY INSURANCE INFORMATION SECTION

SCHOLARSHIP SECTION

Hello!

Let's keep in, Touch!

Top Links

Required Information: Intake forms that are submitted without the required information will not be processed

Restrictions & Exclusions

CLIENT INFORMATION SECTION

** DO NOT CONTINUE OR SUBMIT ** We thank you for your interest in Awetism Wonderland but a diagnosis code of F84.0 and a referral from a physician is required to enroll as a patient. Please contact us again once you have a physician's diagnosis.

** DO NOT CONTINUE OR SUBMIT ** In order for your intake form to be processed, you need to (1) have a diagnosis of F84.0 (Autism Disorder) and (2) Not be looking for PT/OT/ST services. Those looking for PT/OT/ST follow up via the following website. https://www.playworkstherapies.com/patient-portal

PARENT/GUARDIAN INFORMATION SECTION

EMERGENCY CONTACT INFORMATION SECTION

PRIMARY CARE PHYSICIAN INFORMATION SECTION

DIAGNOSIS & SERVICES SECTION

PRIMARY INSURANCE INFORMATION SECTION

We do not currently accept the following insurance for ABA Therapy

SECONDARY INSURANCE INFORMATION SECTION

SCHOLARSHIP SECTION

Let’s Connect

DO NOT CONTINUE OR SUBMIT We thank you for your interest in Awetism Wonderland but a diagnosis code of F84.0 and a referral from a physician is required to enroll as a patient. Please contact us again once you have a physician's diagnosis.

DO NOT CONTINUE OR SUBMIT In order for your intake form to be processed, you need to (1) have a diagnosis of F84.0 (Autism Disorder) and (2) Not be looking for PT/OT/ST services. Those looking for PT/OT/ST follow up via the following website. https://www.playworkstherapies.com/patient-portal